Population Health
Management: Care
Coordination and
Data Workflow
A Town Hall Event by the C&BI
Population Health-Accountable Care
Task Force
May 27, 2015
HIMSS Town Hall Series
This is an informal public meeting that gives the
members of a community an opportunity to get
together to discuss emerging issues and to voice
concerns and preferences for their community.
Today’s Event:
Population Health
Management: Care
Coordination and
Data Workflow
Town Hall speakers:
Moderator:
Alan Gilbert, MPA, FHIMSS
Chief Growth Officer
TEAM of Care Solutions
Alan.Gilbert@TEAMofCare.com
John Middleton, MD, MS
Diplomate, Clinical Informatics, ABPM
VP/CMIO, SCL Health System
john.middleton@sclhs.net
Antonio Linares, M.D.
Regional Vice President, Medical Director
Anthem Blue Cross - Health and Wellness Solutions
Tony.Linares@anthem.com
Executive Summary
1. Population Attribution models were shared and discussed in the
first HIMSS Town Hall Meeting
2. Population Health Management is the topic for today’s Town Hall
Meeting and will cover the following topics:
 Definition of population health and key determinants
 Examples of population health improvement (Triple Aim, PCMH)
 TEAM Coordination of Care to drive population health
 Cost and quality data drivers
 TEAM, data workflow to support providers
 Impact of Non-medical determinants of health
4
What Is Population Health?
• Historically, the term “population health” has been more
commonly used in Canada than in the United States
• A simple definition is “the health outcomes of a group of
individuals, including the distribution of the outcomes within
the group,”*
• The Triple Aim- defines 3 inter-dependent aspects:**
- Improving the health of a population
- Improving the patients experience of care
- Reducing the per capita costs of care for populations
* David Kindig, MD, PhD, and Greg Stoddart, PhD- Models for Population Health, AJPH 2003
**Don Berwick, Health Affairs – The Triple Aim: Care, Health and Cost, May 2008, vol. 27
Population Health Includes:
1. Health outcomes for a defined group that is at risk
(based on agreement of metrics and measures of
health)
2. Patterns of specific health determinants for the group
at risk
3. Specific health policies and key interventions that link
the above outcomes with the health determinants*
*Policies, process and procedures are developed at the organization or
medical group or ACO level
Key Considerations
• Determinants of health may be both medical and nonmedical (important in attribution and risk assessment)
• Population health determinants create a framework to
drive policy development, research focus and resource
allocation
• Measurement of population health includes
consideration of the relative cost-effectiveness of
resource allocation to multiple determinants of health
and outcomes.
What are Non-medical Determinants
of Health?
• Risks regarding access to health care and resources,
housing, food and income, security, education,
employment, and safety
• Underserved children are disproportionately impacted,
widening medical and developmental outcomes
disparities
• Early detection and mitigation of socioeconomic and
environmental risks within a pediatric primary care
practice has the potential to improve outcomes
Reference: Andrew F. Beck, MD, MPH, Cincinnati Children’s Hospital Medical Center and excerpts from the
Meharry Medical College Journal of Health Care for the Poor and Underserved 24 (2013): 1063- 1073
Cincinnati emergency room and hospital use rates and code violations
CCHMC
Cincinnati emergency room and hospital use rates and code violations
Objective 2
HCVD significantly associated
with asthma emergency and
hospital utilization rates after
adjust for poverty (p=0.01)
Population Health Management:
Patient Centered Medical Home
(PCMH) Case Study*
PCMH Providers Outperform Peers on Quality
Measure Bundles
87.9%
83.8%
82.4%
79.2%
76.9%
PCMH
Non-PCMH
77.6%
73.7%
72.9%
62.1%
52.7%
Adult Prevention
Annual Monitoring for
Persistent Meds
Diabetes Care
Other Acute &
Chronic Care
Measures
Pediatric Prevention
Data from Q4 2014
* Anthem Blue Cross year 1 results from 2013 to 2014
11
Population Health
Management: Improves
Patient Satisfaction
Change in member experience scores, (2013-2014)
+11
+11
PCMH
Non-PCMH
+5
+4
+3
+2
+1
+1
Appointment for
Urgent Care
as Soon as Needed
Providers Show
Respect for
What Patients Say
Providers Spend
Enough Time
with Patient
Provider Probed
on
Behavioral Health
•
Members get appointments for urgent care right away
•
Physicians and staff are attentive, thorough and available
•
Members feel more respected and satisfied
* Anthem Blue Cross year 1 results from 2013 to 2014
12
Impact on Personal Health Care
Per Capita Costs
$8.75 PaMPM (3%)
Lower costs in the first program year
Anthem Blue Cross 2013- 2014
Trends from providers indicate they are changing their practice behaviors.
7.6% fewer acute inpatient admits per 1,000
4.8% PaMPM decrease in outpatient surgery costs
5.4% fewer inpatient days per 1,000
3.9% decrease in acute admissions for high risk patients with chronic conditions
1.5% increase in PCP office visits for members with high risk chronic conditions
1 Gross savings before provider gain share. Performance period (7/1/13 – 6/30/13). Per attributed member per month.
13
Part 2
Spotlight on Active TEAM Care Coordination
and Data-Workflow Transformation
Air Traffic
Controllers
Care Traffic
Controllers
Source: Care Traffic Controllers - John Halemka, MD Professor of Medicine at Harvard Medical School and the CIO
of Beth Israel Deaconess Medical Center (BIDMC) in Boston
15
TEAM Coordination Across the Full
Continuum of Care
Program / Workflow Example:
Transition from SNF to Home w/
Home Care
Primary Care
•Med Rec
Behavioral
Health
Social Work
•Housing Assessment
•Assessment
Patient
Unified
Coordination
Plan
Transition of
Care
Home Health
•Bed Set Up
•Transition
Checklist
Transportation
•SNF to Home
16
TEAM Coordination Actions are Defined
and Routed by Program Algorithms
17
Lack of Care Coordination Drives Up
Costs
Source: Identifying and Quantifying the Cost of Uncoordinated Care: Opportunities for Savings and Improved Outcomes,
Mary Kay Owens, R.Ph.,C.Ph, Institute of Medicine, 2009.
18
Cost and Quality Control Occur at All
Points Across the Continuum of Care
9%
PCP
35%
Acute
18%
Post
Acute
Home
9%
14%
6%
7%
Percentages Shown are the Share of Medicare Spending at Each Stage of Care
19
Care Coordination Workflow
Infrastructure Across All Points of
Care
PCP
Acute
Post
Acute
Home
20
Turning Data into Systematic Action
Through Care Coordination Work Flow
and Management
21
Workflow & Content to Support
Providers, Care Coordinators,
Administrators, & Patients
22
In the Provider Workflow
23
In the Provider Workflow
24
Town Hall Discussion
•
How does population health management differ from the historical
“capitation models”?
•
Why is the attribution of the providers member panel so important in
population health management?
•
What are the greatest challenges for providers in care coordination and
the use of technology to improve data workflow?
•
Non-medical determinants of health were mentioned early in the
presentation as being important for population health management. Can
you elaborate more on this topic?
25
Next Steps
Let’s continue the conversation
and learning
• Blog posts
• Key findings and take-aways
• Articles
FY15 C&BI Leadership Information
Committee Chair:
JD Whitlock, MPH, MBA, CPHIMS
Vice President, Clinical & Business Intelligence
Mercy Health
JDWhitlock@mercy.com
Population Health-Accountable Care Task Force Co-Chairs:
William Beach, MBA, MLA, PhD
Jennifer Jackson
Regional Director, Regulatory Readiness, Northern Region, Senior Director, IT Population Health Data Solutions
St. Joseph Health System
Banner Health
William.Beach@stjoe.org
Jennifer.Jackson@bannerhealth.com
Community Co-Chairs:
Michael Brooks, BS, MBA, CPHIMS
Specialist Leader
Deloitte Consulting LLP
mibrooks@deloitte.com
Mike Berger, PE, CPHIMS
Chef Analytics Officer
Affinity Health Plan
Mberger@affinityplan.org
HIMSS Community Organizers | Staff Liaisons:
Shelley Price, MS, FHIMSS
Director, Payer & Life Sciences, HIMSS
sprice@himss.org
Nancy Devlin
Senior Assoc., Payer & Life Sciences, HIMSS
ndevlin@himss.org
Thank you!